Vocational rehabilitation after lung resection due to bronchial carcinoma (author's transl)

Problems of vocational rehabilitation after radical operation of 307 patients with bronchial carcinoma, who are still living 3 years after the operation are analysed. Preoperative relation of professional groups: Employees 46%, industrial workers 28%, independent professions 15%, agricultural professions 11%. The success of rehabilitation is dependent on profession extent of resection, and other concomitant diseases.     

Local recurrence and five year survival after abdominoperineal resection of the rectum due to rectal carcinoma

In the period 01.01.1991-12.31.1996, 523 operations due to rectal carcinoma were performed on the First Surgical Clinic, the Third Department for Colorectal Surgery. Most common localization of tumor was in the distal third of the rectum 65.2%. In the middle third, there were 28.9% and in the upper, intraperitoneal third 5.9%. We performed 286 low anterior stapled resections, 93 anterior resections with hand-sewn anastomosis and 144 Abdominoperineal excisions of rectum (Miles procedure). Pathohistological examination revealed adenocarcinoma in all cases. In this study we analyzed local recurrence and five-year survival after long-term follow-up in the group where Miles procedure was carried out as a potentially curative procedure (except 4.9% cased with Dukes D stage). There were 74.3% males and 23.7% females median age 59.2 years. According to Dukes classification there were 4.9% in stage A, 47.2% in stage B, 43.1% stage C, and 4.9% stage D. There were 4(2.7%) postoperative deaths. Recurrence of the disease was registered in 44 (30.5%) patients. Local recurrence alone was found in 14 (9.7%) patients, while distant spread was registered in 30 (20.8%) patients. At present, the median follow-up is at 72.9 months. Analysis by the Kaplan-Meier's test shows cumulative survival of 61%, and disease free survival of 63.4% at 60 months of the follow-up. Dukes C is associated with a very poor prognosis; survival after 60 months of follow up shows cumulative Survival of 0.35 while Dukes B has far better prognosis (0.86). Analysis of disease free survival by Dukes stage shows that Dukes C has the worst prognosis (disease free survival 0.36 after 60 months), while stage B has much better prognosis (0.84). Local recurrence analysis by the Kaplan-Meier's test shows disease free survival of 84.9% at 60 months of follow-up. Analysis of local recurrence by Dukes stage shows 1.00% disease free survival for cases in stage A, 0.94 for Dukes B and 0.66 for Dukes C, while overall comparison between groups regarding local recurrence using the Wilcoxon (Gehan) statistic shows statistically significant difference (p-0.005). There is no statistical difference between Dukes A and Dukes B cases in distribution of local recurrence.     

Value of radiotherapy for tumour on the bronchial stump after resection for bronchial carcinoma.

Two groups have been selected from 1000 patients who had lobectomy or pneumonectomy for bronchial carcinoma. The first group was of 26 patients with tumour affecting the mucosa of the resected bronchial margin reported histologically at the time of surgery. Twelve of these were given postoperative radiotherapy but with no apparent benefit, either in the incidence of recurrence of tumour at the bronchial stump or in five-year survival. The second group was of 17 patients who developed recurrence of tumour at the bronchial stump, bronchoscopically confirmed, some time after surgery. In six of these cases the recurrence was detected while it was confined to the bronchial stump region, and these patients were then given radiotherapy. Five of the six survived five years after radiotherapy, with complete eradication of the tumour recurrence confirmed by repeat bronchoscopy. In 11 cases the tumour recurrence was not detected until it had become more extensive. Radiotherapy may also have prolonged survival in some of these patients, although none survived five years.     

原发性肝癌肝切除术后复发患者的肝移植治疗

目的观察肝移植治疗原发性肝癌肝切除术后复发患者的疗效。方法回顾性分析11例原发性肝癌肝切除术后复发接受经典原位肝移植治疗的受者的临床资料,观察移植效果。结果在围手术期,1例术后发生移植肝功能不全和凝血功能障碍并发肾功能衰竭死亡;1例术后出现急性胰腺炎,给予生长抑素治疗10d缓解;2例发生急性排斥反应,行大剂量甲泼尼龙冲击治疗3d逆转。10例受者顺利出院。出院后,3例分别于术后第5个月、第7个月、第19个月死于肝癌复发,1、2年受者存活率分别为72．7％（8／11）和63．6％（7／11）,至今最长存活的1例已达4年余。获长期存活的受者肝癌肝切除术前原发病均为小肝癌,肝切除术后复发行肝移植时肝癌均符合Milan标准。结论小肝癌行肝癌肝切除术后应密切随访,如发现肝癌复发且符合Milan标准可考虑行肝移植治疗,患者仍有可能获较长时间生存。     

肝细胞癌切除术后复发再手术治疗

目的　探讨肝细胞癌手术后复发的治疗经验。方法　回顾性分析 1995～ 2 0 0 3年手术治疗 38例肝癌切除术后复发的临床资料。结果　再次手术切除 32例 ,姑息性手术 6例 ,手术后平均生存期超过 14个月。结论　肝细胞癌术后复发是影响病人长期生存的重要原因 ,选择有适应证的病例再次手术切除能延长病人的生存时间。     

经骶尾、腹腔联合切除治疗直肠癌前切除术后局部复发

目的探讨直肠癌前切除术后局部复发病例的再手术治疗成绩并其临床意义。方法对1999年1月至2004年1月间43例直肠癌前切除术后局部复发再手术病例的临床资料进行回顾性分析。结果手术采用折刀体位,经骶尾、腹腔联合切除术式,43例中27例行根治性切除术,16例行姑息性切除术,根治性切除组的术后3年、5年生存率分别为59.3%、48.1%,明显高于姑息性切除组的25%、18.8%（P〈0.05）。结论经骶尾、腹腔施行直肠癌前切除术是治疗直肠癌切除术后肿瘤局部复发的有效方法。     

Intrahepatic recurrence after resection of hepatocellular carcinoma complicating cirrhosis.

To determine whether a careful evaluation of tumor extension by preoperative computed tomography scan after intra-arterial injection of ultrafluid lipiodol and by intraoperative ultrasound examination reduced the recurrence rate of hepatocellular carcinoma after resection, a series of 47 cirrhotic patients with a single tumor operated on from 1984 was studied. Alphafetoprotein level was less than 100 ng/mL in 26 patients (55%), size of the tumor was less than 5 cm in 28 patients (59%), and capsule was present in 30 patients (63%). The resection was performed with free margin measuring 1 cm or more. The overall cumulative survival rates at 3 and 5 years were 35% and 17%, respectively. Intrahepatic recurrence was observed in 28 patients (60%), located less than 2 cm from the resection margin in only four patients. The cumulative intrahepatic recurrence rate at 3 years was 81% and was significantly higher in patients with tumor greater than or equal to 5 cm and in patients with preoperative alphafetoprotein level of greater than or equal to 100 ng/mL. In this series the cumulative intrahepatic recurrence rate at 5 years was 100%. This high recurrence rate after resection, even with careful evaluation of tumor extension, indicates that liver transplantation might be envisaged for the treatment of cirrhotic patients with resectable hepatocellular carcinoma.     

Implications of histologically reported residual tumour on the bronchial margin after resection for bronchial carcinoma.

A group of 64 cases with histologically reported residual tumour on the bronchial margin after resection for bronchial carcinoma has been examined. Carcinoma in situ of the bronchial mucosa was described in nine cases, invasive carcinoma of the bronchial mucosa in 29, peribronchial malignancy in 18, and lymphatic permeation in eight. Survival with peribronchial malignancy and lymphatic permeation was poor. Nevertheless, the finding of earlier workers that residual mucosal tumour at the margin of the resected bronchus may not adversely affect survival has been confirmed. The reason for the prolonged survival of some patients despite reported tumours of the bronchial stump mucosa may be that such reports are sometimes artefactual, and two possible mechanisms for this are discussed.     

Multivariate analysis of recurrence after anterior resection for colorectal carcinoma

We performed a multivariate analysis of survival data from 278 patients who underwent potentially curative anterior resection with hand-sewn anastomosis for nonobstructing colorectal carcinoma to evaluate the interaction of the resection margin with distance from the anal verge and their contributions to local and distant recurrence. Cumulative 5-year disease-free survival was 66 percent for the 258 patients with complete follow-up. Forty-nine patients (19 percent) had local recurrence and 42 (16 percent) developed initial distant metastases. Local recurrence rates increased with increasing age and with more advanced Dukes' stage. It developed in twice as many patients with colostomies as without colostomies. Distant metastases developed significantly more often in patients with nodal involvement and in patients with resection margins exceeding 3.5 cm. Forty-four percent of patients with lesions within 14 cm of the anal verge resected with margins of at least 3.5 cm developed distant recurrence. This study suggests that aggressive pelvic dissection to achieve resection margins greater than 3.5 cm may contribute to tumor dissemination and subsequent distant metastases.     

进展期胃癌根治术后复发的处理

尽管胃癌的诊治取得了长足的进步,但是仍有39％～65％进展期胃癌患者在根治术后出现复发,大部分在术后2年内复发。由于缺乏预测根治术后复发风险、复发时间、复发形式的有效方法,而且复发性胃癌的处理非常棘手,手术切除率低、患者耐受性差、缺乏有效的延长生存期的治疗措施,因此．临床上应实行预防为主的策略。早期发现原发癌,予以彻底根治术,辅以恰当的放、化疗是预防胃癌术后复发的根本措施。     

Predictors and patterns of recurrence after resection of hepatocellular carcinoma

BACKGROUND: The majority of patients with hepatocellular carcinoma (HCC) who undergo complete tumor resection subsequently develop tumor recurrence. The objectives of this study were to determine the risk factors for recurrence of HCC after hepatectomy and to examine the outcomes once tumor recurrence occurs. STUDY DESIGN: From February 1990 to May 2001 a total of 164 patients underwent liver resection for HCC at our institution and were prospectively followed. Time to recurrence and survival after recurrence were determined by Kaplan-Meier analysis. Patient, tumor, and treatment characteristics were tested for their prognostic significance by univariate and multivariate analysis using the logrank test and the Cox proportional hazards model, respectively. RESULTS: The median patient age was 64 years (range 21 to 87 years) and 106 patients (65%) were male. After a median followup of 26 months, 90 patients (55%) have developed recurrent cancer. Among them, 75 patients (83%) had tumor detectable in the liver, which was the only site of disease in 67 (74%). In all, 15 patients (20%) had extrahepatic disease (7 lung, 4 peritoneum, 2 pancreas, 1 bone, and 1 brain). The median time to recurrence was 24 months (range 1 to 274 months). Predictors of recurrence on univariate analysis were tumor size greater than 5 cm, more than one tumor, cirrhosis, vascular invasion (microscopic or macroscopic), and tumor satellites. On multivariate analysis only tumor size greater than 5 cm (p = 0.04) and vascular invasion (p = 0.01) predicted recurrence. The median survival after recurrence was 11 months (range 0 to 60 months). Of the 90 patients who developed tumor recurrence 49 (67%) were able to undergo additional ablative or surgical therapy (33 embolization, 9 ethanol injection, and 14 re-resection). On multivariate analysis vascular invasion in the original tumor predicted poor survival after recurrence (p = 0.009). CONCLUSIONS: The liver is the predominant site of first recurrence after resection of hepatocellular carcinoma, and once recurrence occurs survival is limited. The current study underscores the need for effective adjuvant therapy for patients with HCC treated with partial hepatectomy.     

Local recurrence after curative anterior resection for carcinoma of the rectum

From 1972 to 1985, 60 patients with rectal carcinoma underwent curative anterior resections. There was a local recurrence in three (5 per cent). Pelvic recurrence was seen in two patients and there was a suture line recurrence in one. The length of the distal margin of the normal bowel or lymph node involvement did not appear to be a significant determining factor of the local recurrence. As for the factor responsible for the recurrence, tumor implantation into the pelvic cavity or into the suture line was suspected. Care should be taken to avoid implantation of tumor cells during operative procedures. There were no local recurrences in patients with lower rectal carcinoma. This finding might be related to the selection of patients with carcinoma of stage I and II.     

Relationship of cell type and lymph node metastasis to survival after resection of bronchial carcinoma.

In the completed adjuvant chemotherapy lung trials conducted by the Veterans Administration Surgical Group, the cell type was recorded in 2,341 of 2,349 curative resections; extent of lymph node involvement was known in all cases. Nodes were normal in 1,231 patients. Five- and ten-year survival computed by the life-table method was 33.7% and 20.4%, respectively. These rates were significantly greater than the 16.2% and 8.8% recorded in 1,118 patients whose nodes showed metastases. Among patients whose cell type was known, five-year survival in 484 with hilar node involvement was 17.4% and was not significantly different from 20.1% in 364 patients in whom only lobar nodes were involved. The survival was 8.9% in 268 patients with cancer in the mediastinal nodes; this was significantly worse than either of the aforementioned groups. A five-year survival of 26.8% in 1,482 patients with squamous cell carcinoma was greater than the 24.3% in 359 with adenocarcinoma and 22.4% in 500 with undifferentiated cell types, but the differences were not significant. Variations between these groups remained nonsignificant when nodes were normal and were of only borderline significance, at the 5% level, when they showed metastasis. When a curative resection has been accomplished, cell-type as classified in this study has little bearing on long-term survival, whereas the presence of node metastasis as well as its location is of the utmost importance.     

Local recurrence after curative anterior resection for carcinoma of the rectum

From 1972 to 1985, 60 patients with rectal carcinoma underwent curative anterior resections. There was a local recurrence in three (5 per cent). Pelvic recurrence was seen in two patients and a there was suture line recurrence in one. The length of the distal margin of the normal bowel or lymph node involvement did not appear to be a significant determining factor of the local recurrence. As for the factor responsible for the recurrence, tumor implantation into the pelvic cavity or into the suture line was suspected. Care should be taken to avoid implantion of tumor cells during operative procedures. There were no local recurrences in patients with lower rectal carcinoma. This finding might be related to the selection of patients with carcinoma of stage I and II.     

Anastomotic recurrence after sphincter saving resection for carcinoma of the rectum

Between 1962 and 1982, 273 patients underwent sphincter saving resection for rectal cancer in my hospital. In 30 of these patients, local anastomotic recurrence was observed (11%). Computer analysis of 64 variables was undertaken to identify factors contributing to the anastomotic recurrence, especially in reference to the resecting line from the tumor, safety margin (AW). The present study shows no positive relationship between the length of normal bowel resected below the tumor, if it overs 2cm in advanced case, and anastomotic recurrence. We advocated the principle that "safety margin should be 4 or 5 cm in the advanced case". But this principle must now be changed. There appears every justification to carry out a curative sphincter saving procedure, resecting a shorter length of rectum -3cm (in vivo)- below the tumor in order to spare the patient a permanent colostomy. But, Borrmann 3 type, annular growth, severe serosal invasion, and undifferentiated or mucinous feature of cancer are the predominant factors associated with anastomotic recurrence and demand the longer length of safety margin as well as extended Miles operation. The causes of anastomotic recurrence in 30 patients have been investigated and searched for respectively. The recurrence in 9 of them seemed to be very unexpectedly and implantation might, therefore, be responsible for it.     

低位直肠癌术后局部复发的相关性分析

目的 探讨低位直肠癌术后局部复发的原因.方法 回顾性分析1990年7月至2006年6月我科收治的低位直肠癌术后局部复发301例患者的临床资料.结果 中、青年组复发率高于老年组,女性患者复发率略低于男性患者,浸润型和溃疡型患者的局部复发率高于肿块型,低分化腺癌的复发率明显高于高、中分化腺癌,Duke＇s B、C期患者术后复发率比Duke＇s A期为高,而且5年生存率低.常见的手术方式均有不同程度的复发,直肠癌侧方淋巴结转移与术后局部复发关系密切.结论 肿瘤本身的病理学特征、患者的自身因素、手术操作都是影响低位直肠癌术后复发的相关因素.     

Local recurrence and survival after radical resection of rectal carcinoma

The results of surgical treatment in 99 cases of rectal carcinoma operated on with curative intent by 26 surgeons were retrospectively analyzed and the resected specimens were reexamined according to the Astler-Coller staging system. No chemotherapy or radiotherapy had been given preoperatively. Local recurrence appeared within 5 years in 37% of the patients (within 2 years in 29%), with highest rate in stage C2 tumours in the lower third of the rectum. The recurrence rate did not differ between operations with abdominoperineal excision (n = 83) or with anterior resection (n = 16). All recurrences were treated with chemotherapy, radiotherapy or operation. Progressive disease without evidence of local recurrence was found in 11 patients. The overall 5-year survival rate was 50%. The respective rates for Astler-Coller stages A, B1, B2, C1 and C2 were 86, 59, 52, 33 and 27%.     

胃肠癌术后复发的外科治疗

胃肠道恶性肿瘤临床主要以胃癌和结直肠癌为主。对于胃癌和肠癌患者来说，影响其预后的主要因素就是肿瘤复发问题。胃癌和结直肠癌同属消化道肿瘤，但术后癌复发的形式却明显不同。胃癌腹膜转移占40％～50％，肝转移占10％～15％；而结直肠癌则相反，肝转移占50％左右；两者预后也不一样，胃癌肝转移预后较差，结直肠癌的肝转移则发展较慢。因此，我们将两者分别加以讨论。